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Inguinofemoral Hernia: Accuracy of Sonography in Patients with Indeterminate Clinical Features

Philip Robinson1, Elizabeth Hensor2, Mark J. Lansdown3, N. Simon Ambrose3 and Anthony H. Chapman3

1 Department of Radiology, Leeds Teaching Hospitals, St. James University Hospital, Chancellor Wing, Beckett St., Leeds LS9 7TF, United Kingdom.
2 Department Of Epidemiology, University Of Leeds, Leeds, United Kingdom.
3 Department of Surgery, Leeds Teaching Hospitals, Leeds, United Kingdom.


Figure 1
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  		Fig. 1A —52-year-old man who presented with left inguinal pain; normal findings were seen on sonography. Line drawing (A) and longitudinal sonography image (B) of left inguinal canal show inferior epigastric vessels (IE) laterally, hyperechoic fibrillar inguinal ligament (arrowheads), and transversalis fascia (arrows). Canal contents are fat, nerves, and hypoechoic vessels (asterisks).

 

Figure 2
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  		Fig. 1B —52-year-old man who presented with left inguinal pain; normal findings were seen on sonography. Line drawing (A) and longitudinal sonography image (B) of left inguinal canal show inferior epigastric vessels (IE) laterally, hyperechoic fibrillar inguinal ligament (arrowheads), and transversalis fascia (arrows). Canal contents are fat, nerves, and hypoechoic vessels (asterisks).

 

Figure 3
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  		Fig. 1C —52-year-old man who presented with left inguinal pain; normal findings were seen on sonography. Line drawing (C) and short-axis sonography image (D) of inguinal canal show oval-shaped canal (arrows) containing multiple hypoechoic vessels (small asterisks). Inferior and deep in relation to canal is psoas muscle (P) with rectus abdominis muscle (RAb) superiorly. Posterior and slightly superior to canal is echogenic margin (arrowheads) of transversalis fascia with preperitoneal fat (large asterisk), bowel, and peritoneum deep to fascia.

 

Figure 4
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  		Fig. 1D —52-year-old man who presented with left inguinal pain; normal findings were seen on sonography. Line drawing (C) and short-axis sonography image (D) of inguinal canal show oval-shaped canal (arrows) containing multiple hypoechoic vessels (small asterisks). Inferior and deep in relation to canal is psoas muscle (P) with rectus abdominis muscle (RAb) superiorly. Posterior and slightly superior to canal is echogenic margin (arrowheads) of transversalis fascia with preperitoneal fat (large asterisk), bowel, and peritoneum deep to fascia.

 

Figure 5
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  		Fig. 2A —61-year-old woman who presented with left inguinal pain from left indirect inguinal hernia. Herniography image shows left indirect hernia (arrows) with contrast material filling distally.

 

Figure 6
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  		Fig. 2B —61-year-old woman who presented with left inguinal pain from left indirect inguinal hernia. Longitudinal sonography image obtained while patient was at rest shows inferior epigastric vessels (IE), inguinal ligament (arrowheads), and transversalis fascia (arrows).

 

Figure 7
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  		Fig. 2C —61-year-old woman who presented with left inguinal pain from left indirect inguinal hernia. Sonogram obtained while patient strained shows that hypoechoic hernia (asterisk) arises lateral to inferior epigastric vessels (IE) expanding canal (thin arrows) and displacing ligament (arrowheads) and transversalis fascia (thick arrows).

 

Figure 8
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  		Fig. 2D —61-year-old woman who presented with left inguinal pain from left indirect inguinal hernia. Short-axis sonography image while patient was at rest shows inguinal canal (arrows).

 

Figure 9
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  		Fig. 2E —61-year-old woman who presented with left inguinal pain from left indirect inguinal hernia. Sonogram obtained while patient strained shows that canal is expanded (arrows) by extension of indirect hernia along its long axis.

 

Figure 10
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  		Fig. 3A —73-year-old woman with left inguinal pain from left direct inguinal hernia. Herniography image shows left direct inguinal hernia (arrows) and surgical clips from previous surgery.

 

Figure 11
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  		Fig. 3B —73-year-old woman with left inguinal pain from left direct inguinal hernia. Longitudinal sonography image obtained while patient was at rest shows inferior epigastric vessels (IE), inguinal ligament (arrowheads), transversalis fascia (arrows), and contents including prominent vessel (asterisks).

 

Figure 12
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  		Fig. 3C —73-year-old woman with left inguinal pain from left direct inguinal hernia. Sonogram obtained while patient strained shows that hernia (asterisk) extends (small arrows) through posterior wall defect (margin marked by large arrows) medial to inferior epigastric vessels (IE).

 

Figure 13
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  		Fig. 3D —73-year-old woman with left inguinal pain from left direct inguinal hernia. Short-axis sonography image obtained while patient was at rest shows canal (arrowheads), prominent vessel (asterisk), and transversalis fascia (arrows).

 

Figure 14
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  		Fig. 3E —73-year-old woman with left inguinal pain from left direct inguinal hernia. Sonogram obtained while patient strained shows that hernia (asterisk) enters through posterior wall defect (margin marked by thick arrows) compressing (thin arrows) contents of inguinal canal (arrowheads).

 

Figure 15
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  		Fig. 4A —33-year-old man who presented with right inguinal pain from right posterior inguinal wall bulging. Herniography image shows broad-based bulge (arrows) of transversalis fascia.

 

Figure 16
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  		Fig. 4B —33-year-old man who presented with right inguinal pain from right posterior inguinal wall bulging. Short-axis sonography image of inguinal canal obtained while patient was at rest shows inguinal canal (arrowheads) and psoas muscle (P), with transversalis fascia lying superiorly and posteriorly (arrows).

 

Figure 17
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  		Fig. 4C —33-year-old man who presented with right inguinal pain from right posterior inguinal wall bulging. Sonogram obtained while patient strained shows that bowel (two asterisks) and preperitoneal fat (one asterisk) are displacing intact transversalis fascia (arrows), which is markedly compressing inguinal canal (arrowheads).

 

Figure 18
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  		Fig. 5A —56-year-old woman with right inguinal pain. Herniography findings were false-negative; right indirect hernia was detected at sonography and confirmed at surgery. Herniography image shows no evidence of inguinal hernia.

 

Figure 19
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  		Fig. 5B —56-year-old woman with right inguinal pain. Herniography findings were false-negative; right indirect hernia was detected at sonography and confirmed at surgery. Longitudinal sonography image obtained while patient was at rest shows inferior epigastric vessels (IE), inguinal ligament (arrowheads), and transversalis fascia (arrows).

 

Figure 20
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  		Fig. 5C —56-year-old woman with right inguinal pain. Herniography findings were false-negative; right indirect hernia was detected at sonography and confirmed at surgery. Sonogram obtained while patient strained shows that hypoechoic hernia (asterisk) consisting of fat arises laterally to inferior epigastric vessels (IE), expanding canal (arrows) and displacing inguinal ligament (arrowheads).

 

Figure 21
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  		Fig. 5D —56-year-old woman with right inguinal pain. Herniography findings were false-negative; right indirect hernia was detected at sonography and confirmed at surgery. Short-axis sonography image of inguinal canal while patient was at rest shows round canal (arrowheads).

 

Figure 22
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  		Fig. 5E —56-year-old woman with right inguinal pain. Herniography findings were false-negative; right indirect hernia was detected at sonography and confirmed at surgery. Sonogram obtained while patient strained shows that canal is expanded by extension of indirect hernia (asterisk) along its long axis, which results in compression of other canal contents (arrowheads).

 

Figure 23
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  		Fig. 6 —Flowchart shows clinical outcome for all patients (n = 59).

 

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